MSHA Form 2000-224 Operator’s Annual Certification of Mine Rescue Team Qual

Operator’s Annual Certification of Mine Rescue Team Qualifications
Form Approved: OMB Number 1219-0144 Approval Expires July 31, 2023

This form is affected by the Privacy Act of 1974

Public reporting burden for this collection of information is estimated to average 31 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing the form. This collection of information is mandatory. You are not required to respond to this collection of information unless it displays a valid
OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: to DOL/MSHA, Office of Standards Regulations and Variances, 201
12th Street South, Suite 401, Arlington, VA 22202-5452, Paperwork Reduction Project (1219-0144), NOTE: Do not send your completed form to this address.

MSHA Mine ID No.:

Contractor ID No.:

Company Name:

Ο

Mine Name:

Mine size:

Team Name:

Type of Team:

Large

Ο

Team is available at all times when
miners are underground

Small

Mine-site

Contract

Composite

Mine Rescue Team is available within 1-hour ground travel time from the Mine Rescue Station
Address of Mine Rescue Station:
1

2

3

State-sponsored

Appropriate mine rescue equipment
is provided, inspected, tested, &
maintained

4

Alternate

5

Member’s name

Employer’s name
Experience working
in underground coal
mine

Ο

Ο

Ο

Ο

Physically fit

Ο

Ο

Ο

Ο

Ο

Ο

New member training Ο Initial 20 hr

Ο Initial 20 hr

Ο Initial 20 hr

Ο Initial 20 hr

Ο Initial 20 hr

Ο Initial 20 hr

Annual training

Refresher training
totals 96 hr or more

Refresher training
totals 96 hr or more

Refresher training
totals 96 hr or more

Refresher training
totals 96 hr or more

Refresher training
totals 96 hr or more

8 hr training every
2 mos; includes
wearing apparatus
for 2 hr

Refresher training
totals 96 hr or more

Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec

Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec

MSHA Form 2000-224, Aug. 2015 revised (Mailing Address), Page 1 of 2

Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec

Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec

Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec

Jan-Feb
Mar-Apr
May-Jun
Jul-Aug
Sep-Oct
Nov-Dec

Operator’s Annual Certification of Mine Rescue Team Qualifications

Trains underground
every 6 mos

Ο Jan-Jun
Ο Jul-Dec

Ο Jan-Jun
Ο Jul-Dec

Ο Jan-Jun
Ο Jul-Dec

Ο Jan-Jun
Ο Jul-Dec

Ο Jan-Jun
Ο Jul-Dec

Ο Jan-Jun
Ο Jul-Dec

Wears apparatus in
smoke annually

Ο

Ο

Ο

Ο

Ο

Ο

Familiar with
operations of mine

Ο

Ο

Ο

Ο

Ο

Ο

Knowledge of
operations &
ventilation of mine

Ο

Ο

Ο

Ο

Ο

Ο

Participates in two
local mine rescue
contests (Insert dates)

Trains at this mine
(Insert dates)

I certify the information above is true and accurate to the best of my knowledge.
Printed Name &
Signature:

Date:

Position held at the mine:

Use of this form is optional.
An underground coal mine operator may file a copy of this form with the appropriate District Manager for each of the two designated
mine rescue teams, that provide coverage for this mine, to certify that each team meets the requirements of 30 CFR Part 49 Subpart B.

MSHA Form 2000-224, Aug. 2015, revised (Mailing Address), Page 2 of 2